SLR - January 2022 - Rebecca Van Dyke

Pedicled Sural Flaps Versus Free Anterolateral Thigh Flaps in Reconstruction of Dorsal Foot and Ankle Defects in Children: A Systematic Review

Reference: Beecher SM, Cahill KC, Theopold C. Pedicled Sural Flaps Versus Free Anterolateral Thigh Flaps in Reconstruction of Dorsal Foot and Ankle Defects in Children: A Systematic Review. Arch Plast Surg. 2021 Jul;48(4):410-416.

Level of Evidence: Level IV

Scientific Literature Review

Reviewed By: Rebecca Van Dyke, DPM
Residency Program: University Hospital - Newark, NJ

Podiatric Relevance: Pediatric foot and ankle trauma is a challenge which requires proficiency in advanced reconstructive techniques. There is paucity in such cases in the podiatric literature. Due to the smaller surface area of the foot and ankle, local flap options are limited and therefore free tissue and regional flaps are the procedures of choice. Therefore, the anterolateral thigh (ALT) flap and pedicled distally based sural artery (DBSA) flap are viable options in foot and ankle defect coverage in pediatric patients. The ALT flap, which has a blood supply based on a branch of the lateral femoral circumflex artery, can be anastomosed with both tibial vessels. Larger defects are noted to fare better with the ALT flap and therefore the decision of which flap to use should be based on defect size. Of importance in pediatric anatomy, although the flap expands as the foot grows, the smaller caliber of a child’s neurovasculature poses a greater challenge with microsurgical anastomosis of the larger vessels of an ALT flap. The DBSA, based on a perforating branch of the peroneal artery, obviates the need of such procedures due to the pedicle’s vascular supply. This article looks to evaluate which flap is superior for this type of pedal defect.

Methods: A systematic review of 19 articles (13 on DBSA and 6 on ALT) reporting outcomes of reconstruction of traumatic pediatric ankle and dorsal foot defects were included in this study. The inclusion criteria for the articles used included the defect location, type of surgical reconstruction, number of patients, patients 16 years old or younger, total number of reconstructive procedures, complications, and outcomes. Exclusion criteria included articles which were not fully accessible, those not available in English language, studies with defects to weight-bearing areas, and those where the flap was used for non-traumatic conditions. The Quality Assessment Tool for Case Series Studies Checklist was used for evaluation.

Results: A total of 221 patients with a median age of 8.2 years were included with a mean follow up time of 40.5 months. The most common etiology was road traffic accident (119/221). Eighty-three patients underwent ALT flap reconstruction versus 138 patients for DBSA flap. The mean surface area of ALT was 91.7 cm^2 and of DBSA was 57.9 cm^2. Patients who underwent DBSA flap reconstruction were more likely to require donor-site grafting versus primary closure (P < 0.001). Furthermore, subsequent flap thinning was statistically significant after ALT reconstruction. Noted complications (with a combined rate of 10 percent) included infection, venous congestion, ulceration, and flap necrosis.

Conclusions: This review did not find any significant difference in superiority of either flap utilized in pediatric dorsal foot and ankle defects. Management of such injuries has progressed in recent years, from primary amputation to now advocating for fasciocutaneous and perforator flap applications. Dorsal foot and ankle reconstruction requires a thin, pliable flap allowing for tendon gliding and excursion to allow for ambulation in regular shoes. Overall, consideration should be given to these flaps when confronted with such a traumatic injury based on extent of defect and surgeon skill set. 

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